How Can We Best Diagnose Severity Levels of Dry Eye Disease: Current Perspectives.

Dry eye disease (DED) is a common ocular condition, but the diagnosis relative to other ocular conditions and the evaluation of severity of the condition has often been difficult. This challenge can be due to clinical signs and symptoms not always correlating with each other. An understanding of the various components which create the condition, as well as the diagnostic measures used to evaluate these components, is useful to the clinician working with DED patients. This review paper will discuss traditional diagnostic options, diagnostic imaging, and Advanced Point of Care testing capabilities to determine the severity level of dry eye disease more adequately.

Improving Pneumococcal Vaccination Rates in Rheumatology Patients by Using Best Practice Alerts in the Electronic Health Records.

OBJECTIVE: To improve pneumococcal vaccination (PV) rates among rheumatology clinic patients on immunosuppressive therapy in the outpatient settings. METHODS: This quality improvement project was based on the pre-post intervention design. Phase I of the project targeted patients with rheumatoid arthritis from 13 rheumatology clinics (January 2013-July 2015) on immunosuppressive therapy to receive the pneumococcal polysaccharide vaccine (PPSV23). In the Phase II study (January 2016-October 2017), all patients on immunosuppressive medications regardless of diagnosis were targeted to receive PPSV23 and the pneumococcal conjugate vaccine (PCV13). The best practice alerts (BPAs) for both PVs were developed based on the Centers for Disease Control and Prevention guidelines, which appeared on electronic medical records for eligible patients at the time of assessment by the medical assistant. The BPA was designed to inform the vaccination status and enable the physician to order the PV, or to document refusal or deferral reasons. Education regarding vaccine guidelines, BPAs, vaccination process, and regular feedback of results were important project interventions. The vaccination rates during pre-post intervention for each study phase were compared using chi-square test. RESULTS: During phase I, PPSV23 vaccination rates improved from a 28% preintervention rate to 61.5% (P < 0.0001). During phase II, 77.4% of patients had received either PPSV23, PCV13, or both, compared to 49.6% of patients in the preintervention period (P < 0.0001). The documentation rates (vaccine received, ordered, patient refusal and deferral reasons) increased significantly in both phases. CONCLUSION: Electronic identification of vaccine eligibility and implementation of BPAs with capabilities to order and document resulted in significantly improved PV rates. The process has potential for self-sustainability and generalizability.

An algorithm for the preoperative diagnosis and treatment of ocular surface disorders.

Any ocular surface disease (OSD), but most commonly, dry-eye disease (DED), can reduce visual quality and quantity and adversely affect refractive measurements before keratorefractive and phacorefractive surgeries. In addition, ocular surgery can exacerbate or induce OSD, leading to worsened vision, increased symptoms, and overall dissatisfaction postoperatively. Although most respondents of the recent annual American Society of Cataract and Refractive Surgery (ASCRS) Clinical Survey recognized the importance of DED on surgical outcomes, many were unaware of the current guidelines and most were not using modern diagnostic tests and advanced treatments. To address these educational gaps, the ASCRS Cornea Clinical Committee developed a new consensus-based practical diagnostic OSD algorithm to aid surgeons in efficiently diagnosing and treating visually significant OSD before any form of refractive surgery is performed. By treating OSD preoperatively, postoperative visual outcomes and patient satisfaction can be significantly improved.

Phacoemulsification of posterior polar cataracts.

Posterior polar cataracts present a unique challenge for the cataract surgeon. This review describes the steps a surgeon can take to overcome these challenges for the successful phacoemulsification of the posterior polar cataract. Proper preoperative examination and diagnostics will allow appropriate preoperative counseling and surgical planning to increase the likelihood of success. Specific techniques for each stage of the procedure are described, all with the aim of protecting the posterior capsule and preserving intraocular lens (IOL) fixation options. Posterior polar cataracts present dilemmas in preoperative evaluation, surgical management, and IOL fixation.

Practice Variation and Effects of E-mail-only Performance Feedback on Resource Use in the Emergency Department.

OBJECTIVES: Higher resource utilization in the management of pediatric patients with undifferentiated vomiting and/or diarrhea does not correlate consistently with improved outcomes or quality of care. Performance feedback has been shown to change physician practice behavior and may be a mechanism to minimize practice variation. We aimed to evaluate the effects of e-mail-only, provider-level performance feedback on the ordering and admission practice variation of pediatric emergency physicians for patients presenting with undifferentiated vomiting and/or diarrhea. METHODS: We conducted a prospective, quality improvement intervention and collected data over 3 consecutive fiscal years. The setting was a single, tertiary care pediatric emergency department. We collected admission and ordering practices data on 19 physicians during baseline, intervention, and postintervention periods. We provided physicians with quarterly e-mail-based performance reports during the intervention phase. We measured admission rate and created four categories for ordering practices: no orders, laboratory orders, pharmacy orders, and radiology orders. RESULTS: There was wide (two- to threefold) practice variation among physicians. Admission rates ranged from 15% to 30%, laboratory orders from 19% to 43%, pharmacy orders from 29% to 57%, and radiology orders from 11% to 30%. There was no statistically significant difference in the proportion of patients admitted or with radiology or pharmacy orders placed between preintervention, intervention, or postintervention periods (p = 0.58, p = 0.19, and p = 0.75, respectively). There was a significant but very small decrease in laboratory orders between the preintervention and postintervention periods. CONCLUSIONS: Performance feedback provided only via e-mail to pediatric emergency physicians on a quarterly basis does not seem to significantly impact management practices for patients with undifferentiated vomiting and/or diarrhea.

Structural Plasticity of the Hippocampus and Amygdala Induced by Electroconvulsive Therapy in Major Depression.

BACKGROUND: Electroconvulsive therapy (ECT) elicits a rapid and robust clinical response in patients with refractory depression. Neuroimaging measurements of structural plasticity relating to and predictive of ECT response may point to the mechanisms underlying rapid antidepressant effects and establish biomarkers to inform other treatments. Here, we determine the effects of diagnosis and of ECT on global and local variations of hippocampal and amygdala structures in major depression and predictors of ECT-related clinical response. METHODS: Longitudinal changes in hippocampal and amygdala structures were examined in patients with major depression (N = 43, scanned three times: prior to ECT, after the second ECT session, and within 1 week of completing the ECT treatment series), referred for ECT as part of their standard clinical care. Cross-sectional comparisons with demographically similar controls (N = 32, scanned twice) established effects of diagnosis. RESULTS: Patients showed smaller hippocampal volumes than controls at baseline (p < .04). Both the hippocampal and the amygdala volumes increased with ECT (p < .001) and in relation to symptom improvement (p < .01). Hippocampal volume at baseline predicted subsequent clinical response (p < .05). Shape analysis revealed pronounced morphometric changes in the anterior hippocampus and basolateral and centromedial amygdala. All structural measurements remained stable across time in controls. CONCLUSIONS: ECT-induced neuroplasticity in the hippocampus and amygdala relates to improved clinical response and is pronounced in regions with prominent connections to ventromedial prefrontal cortex and other limbic structures. Smaller hippocampal volumes at baseline predict a more robust clinical response. Neurotrophic processes including neurogenesis shown in preclinical studies may underlie these structural changes.